Maraveyas Anthony, Muazzam Iqtedar, Noble Simon, Bozas George
aQueen's Centre for Oncology and Haematology, Castle Hill Hospital bJoint Centre for Cancer Studies, Hull York Medical School, Cottingham cMarie Curie Palliative Care Research Centre, Cardiff University, Cardiff Wales, UK.
Curr Opin Support Palliat Care. 2017 Dec;11(4):347-354. doi: 10.1097/SPC.0000000000000309.
To update on new data for low-molecular weight heparins (LMWHs) and the direct oral anticoagulants (DOACs) for the treatment and prevention of cancer-associated thrombosis (CAT), to discuss progress with the risk-adaptive management scores (RAMS) and update on increased dose primary thromboprophylaxis (IDPTP).
In a pooled meta-analysis of 1132 cancer patients who received DOACs vs. vitamin K analogues (VKAs), recurrence of venous thromboembolism (VTE) was reduced from 6.0% on VKA schedules to 3.9% on DOACs. In a randomized trial of warfarin vs. once daily sc. tinzaparin (175 IU/kg), cumulative 6-month VTE incidence reduced from 10.5 to 7.2% [hazard ratio, 0.65 (95% confidence interval, 0.41-1.03); P = 0.07]. Despite early suggestions that DOACs may have a role in CAT, 3-6 months of LMWH remain the standard for initial treatment of CAT. A prospective comparison of RAMS found the Vienna CATS or the PROTECHT scores superior to the Khorana score but concluded that RAMS did not perform well enough to be used in the clinic. An efficacy scale of LMWHs in pancreatic cancer facilitates IDPTP. Practical implementation of IDPTP was needed to control the 40% VTE incidence of the HALO-109-202 study in metastatic pancreatic cancer.
DOACs have some encouraging data, but LMWHs remain the standard for CAT treatment. RAMS generated to predict VTE occurrence or recurrence are still of unproven significance and IDPTP for advanced pancreatic cancer has tools and guidance for implementation.
更新低分子量肝素（LMWH）和直接口服抗凝剂（DOAC）用于治疗和预防癌症相关血栓形成（CAT）的新数据，讨论风险适应性管理评分（RAMS）的进展以及增加剂量的一级血栓预防（IDPTP）的更新情况。
在一项对1132例接受DOAC与维生素K拮抗剂（VKA）治疗的癌症患者的汇总荟萃分析中，静脉血栓栓塞（VTE）复发率从VKA方案的6.0%降至DOAC方案的3.9%。在一项华法林与每日一次皮下注射替扎肝素（175 IU/kg）的随机试验中，6个月累积VTE发生率从10.5%降至7.2%[风险比，0.65（95%置信区间，0.41 - 1.03）；P = 0.07]。尽管早期有观点认为DOAC可能在CAT治疗中发挥作用，但3 - 6个月的LMWH治疗仍是CAT初始治疗的标准。一项对RAMS的前瞻性比较发现，维也纳CATS或PROTECHT评分优于Khorana评分，但得出结论认为RAMS在临床应用中表现不够理想。LMWH在胰腺癌中的疗效量表有助于IDPTP。需要实际实施IDPTP来控制HALO - 109 - 202研究中转移性胰腺癌40%的VTE发生率。
DOAC有一些令人鼓舞的数据，但LMWH仍是CAT治疗的标准。用于预测VTE发生或复发的RAMS的意义仍未得到证实，晚期胰腺癌的IDPTP有实施工具和指导。
